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The group clinic model pioneered by Kaiser Permanente-Colorado’s Cooperative Health Care Clinic (CHCC) now is being successfully applied in the management of fibromyalgia and diabetes. (See "Group clinics fold elder care into new model," QI/TQM, February 2000.) In both group clinics, patients are seen by physicians much sooner, health care resources are leveraged more efficiently, and the patients are demonstrating improved self-care skills.
Colleen Miller, RN, MSN, adult nurse practitioner and rheumatology nurse practitioner at the Kaiser Permanente Franklin facility in Denver, has noted a significant decrease in visits to the rheumatology department since she began her group in 1998. This decrease applies to both initial visits and returns.
Paulanne Balch, MD, physician in charge at the Hidden Lake Kaiser Clinic also in Denver, began her diabetes group last spring. "We have noticed a 1% drop in the first four months of the program in hemoglobin A1c, which is a 15% improvement," she notes. "We consider that a great win for our program."
Both groups grew, not only because of the CHCC model but from a desire to improve access to care. Not only could patients see physicians sooner and more often, the health care professionals could leverage their teaching time. "Patients can receive primary care, mental health care, and stress-management education all in the same place," Miller says.
"I was conducting weight-management classes and found that so many issues were common to diabetics, I was repeating myself in office one-on-one [sessions]," says Balch. "I felt I would have more time to teach if we could work as a group. I also felt the patients would be the best teachers of each other."
Balch’s group of 18 patients meets once a month for 1½ hours. The ages range from 30s to 80s. In each session, they follow a "liturgy" centered around key learnings. "There are several important things participants need to share with the class — that they are diabetic and how long they have been diabetic; what their morning blood sugar was; what their meds are; and what their last three-month hemoglobin A1c was," Balch explains. Hemoglobin A1c is a key number for managing diabetes, he says, yet most participants had no idea what it was. "I decided to make this the key learning. Now, when I ask, they know their number."
As patients talk, vitals are taken, and medications are confirmed, and in some cases, adjusted. Group leaders ask participants how often they take their sugars, confirm patients have current labs, and perform a diabetic foot exam on each person attending.
New members of Miller’s fibromyalgia group begin with a four-hour educational intervention. Each group, composed mostly of women, includes 20 to 30 participants. Participants receive an information packet and a questionnaire to complete on a hand-held "point-of-view box." The questionnaire, which screens for such variables as illness intrusiveness and psychiatric disorders, is sent to the primary physician. Later the same morning, a psychologist will assess the need for mental health intervention, and when required, will tell the attending physician.
Next, Miller explains the group model to the patients, particularly how the multidisciplinary approach enhances their access to care. "We allow plenty of time for questions," says Miller. "This is a huge benefit for the group. It offers a validation of symptoms and mutual support that we think is superior to what [patients] experience in a one-on-one situation."
In a day interspersed with frequent breaks, new participants also are given a medical overview of fibromyalgia by a physician, as well as tips on medical management. Next, a psychologist speaks to the group and explains how stress can make symptoms worse. Deep-breathing and muscle-relaxation techniques are demonstrated. Then the patients fill out a questionnaire that measures stress levels. "If the need is there, they can see a psychologist the same day," says Miller.
Finally, a physical therapist demonstrates stretching exercises and other pain management techniques, and encourages the patients to try them. At the conclusion of the session, participants are given a video to help them and to share with family members. "We feel the tape gives them the power to self-manage their condition," says Miller.
After the initial session, patients participate in an ongoing monthly support group facilitated by Miller and the psychologist. There, they review special concerns, share resources, and offer each other encouragement.
Balch shares Miller’s firm contention that the group clinic approach is far superior in a disease-management setting. "The patients love it," she asserts. "They learn more, they find more out about community resources, they help each other cope with problems, and they feel less isolated. One person told the group he had stopped exercising because of arthritis pain, and another said, You can’t do that, you’ll be dead!’ This person coping with the same problem had more authority than I ever could."
In the management of chronic illness, Balch declares, the medical dyad can actually collude with patients’ resistance. "They don’t get any other reinforcement," she explains. "The broader group support gives them that."
For more information on fibromyalgia group clinics, contact: Colleen Miller, Kaiser Permanente Franklin, 2045 Franklin, Denver, CO 80205. Telephone: (303) 764-4493.
For more information on diabetes group clinics, contact: Paulanne Balch, MD, Hidden Lake Kaiser Clinic, Denver. Telephone: (303) 657-6803.